Polycystic ovary syndrome

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Chapter 28 POLYCYSTIC OVARY SYNDROME

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. Women with PCOS often have irregular menses, obesity, infertility, and hirsutism.

Diagnostic criteria from the 2003 meeting of the European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine (ESHRE/ASRM) stressed that PCOS could be diagnosed only if other causes of hyperandrogenism were ruled out; such causes include androgen-secreting tumors, Cushing syndrome, and congenital adrenal hyperplasia. In addition, two of three criteria must be present to make the diagnosis: oligo-ovulation or anovulation, signs of hyperandrogenism, and ultrasound evidence of polycystic ovaries. These newer criteria include atypical manifestations of PCOS.

PCOS is a worrisome disease because of the potential complications. Women with PCOS are at higher risk for infertility, first-trimester miscarriages, endometrial hyperplasia (with chronic anovulation), type 2 diabetes mellitus, dyslipidemia, and cardiovascular disease. These complications can be treated and prevented; therefore, it is important to diagnose PCOS.

Causes of Polycystic Ovary Syndrome

The cause of polycystic ovary syndrome is not completely understood. It involves the dysregulation of complex hormone cycles that leads to luteinizing hormone excess, androgen excess, insulin resistance, and chronic anovulation. There is a probable genetic predisposition to PCOS that is affected by environmental factors, especially obesity.

Key Historical Features:

✓ Medical history

• Type 2 diabetes mellitus, hyperlipidemia, hypertension, hyperprolactinemia, or thyroid disease

✓ Medications

✓ Menstrual history

• Irregular menses or amenorrhea (may be present in patients with PCOS)

• Secondary amenorrhea (may also indicate pregnancy or hyperprolactinemia)

✓ Reproductive history

• Anovulatory cycles in PCOS (results in infertility)

• When pregnancy does occur, higher risk for recurrent first-trimester miscarriages

✓ Family history

• PCOS, type diabetes mellitus, hypertension, hyperlipidemia, thyroid disease, and nonclassical congenital adrenal hyperplasia

✓ Constitutional symptoms

• Fatigue, cold intolerance, and constipation (may indicate hypothyroidism)

• Palpitations, heat intolerance, anxiety, diarrhea, and weight loss (may indicate hyperthyroidism)

✓ Skin symptoms

• Hirsutism and acne (indicative of hyperandrogenism)

• Dry skin and brittle hair (may be suggestive of hypothyroidism)

✓ Neurologic symptoms

• Headaches and visual disturbance (may be suggestive of a pituitary tumor)

Key Physical Findings

✓ Vital signs

✓ General assessment

• Obesity (in PCOS is central in distribution)

• Moon facies or a buffalo hump (can be suggestive of Cushing syndrome)

• Deepening of the voice (a sign of virilization and is a red flag for an androgen-secreting tumor)

• Acromegaly (suggestive of a pituitary tumor)

✓ Head and neck examination

• Visual field defect (suggestive of a pituitary tumor)

• Goiter (suggestive of hypothyroidism)

✓ Cardiovascular

• Hypertension (can be indicative of underlying cardiovascular disease, metabolic syndrome, or Cushing syndrome)

• Bradycardia (may be suggestive of hypothyroidism)

• Tachycardia (may be suggestive of hyperthyroidism)

✓ Skin examination

• Acanthosis nigricans (associated with insulin resistance)

• Abdominal striae and easy bruising (can be indicative of Cushing syndrome)

• Hirsutism and acne (indicative of hyperandrogenism)

• Male-pattern alopecia (rare in PCOS and could be suggestive of an androgen-secreting neoplasm)

✓ Pelvic and vaginal examination

• Palpable enlargement of ovaries, as a result of ovarian cysts

• Clitoromegaly (a sign of virilization)

Suggested Work-Up

The key to evaluating for PCOS is to rule out other diseases that can cause similar signs and symptoms:

Pregnancy test	To rule out pregnancy
Serum prolactin level measurement	To evaluate for hyperprolactinemia/pituitary adenoma
Fasting blood glucose measurement or glucose tolerance test	To evaluate for diabetes or glucose intolerance
Fasting lipid panel	To evaluate for hyperlipidemia
Thyroid-stimulating hormone measurement	To evaluate for hyper- or hypothyroidism
Dehydroepiandrosterone sulfate (DHEAS)	To evaluate for hyperandrogenism and rule out an androgen-producing tumor
Free testosterone	To evaluate for hyperandrogenism and rule out an androgen-producing tumor

Additional Work-Up

On the basis of the history and physical examination and the results of the tests just listed, a more extensive work-up may be warranted:

Pelvic ultrasonography	To evaluate for cystic ovaries, ideally performed on cycle days 3, 4, or 5 and with a vaginal probe
Total testosterone measurement	To evaluate for hyperandrogenism and rule out an androgen-producing tumor
Androstenedione measurement	To evaluate for hyperandrogenism
Serum 17-hydroxyprogesterone measurement	To evaluate for non-classic congenital adrenal hyperplasia
Dexamethasone suppression test	If Cushing syndrome is suspected
Twenty-four-hour urine cortisol measurement	If Cushing syndrome is suspected
Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) measurements	For a high LH/FSH ratio, which is suggestive of PCOS (usually 3:1 or higher)
Estradiol level measurement	A low estradiol level in conjunction with a high FSH level is suggestive of premature ovarian failure in a patient with amenorrhea
Fasting insulin measurement	To evaluate for insulin resistance (a ratio of fasting glucose to insulin of 4.5 or lower indicates insulin resistance)
Endometrial biopsy	If endometrial hyperplasia or carcinoma is suspected

FURTHER READING

Buccola JM, Reynolds EE. Polycystic ovary syndrome: a review for primary providers. Prim Care Clin Office Pract. 2003;30:697-710.

Buggs C, Rosenfield RL. Polycystic ovary syndrome in adolescence. Endocrinol Metab Clin. 2005;34:677-705.

Carmina E. The spectrum of androgen excess disorders. Fertil Steril. 2006;85:1582-1585.

Habif TP. Clinical Dermatology, 4th. St. Louis: Mosby, 2004.

Hart R, Norman R. Polycystic ovarian syndrome—prognosis and outcomes. Best Pract Res Clin Obstet Gynaecol. 2006;20:751-778.

Richardson MR. Current perspectives in polycystic ovary syndrome. Am Fam Physician. 2003;68:697-704.

The Rotterdam ESHRE/ASRM–Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19(1):41-47.

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